IJCRR - Vol 10 Issue 03, February
Date of Publication: 01-Feb-2018
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Albendazole Resistant Neurocysticercosis- Rare Unusual Case Report
Author: Rattilal Meena, Ankur Mittal, Neera Samar, Mehul Prajapati
Abstract:A 25 years old female patient presented with history of recurrent seizures since 2 years. Patient was diagnosed as a case of Neurocysticercosis based on Magnetic resonant imaging (MRI) of brain finding in January 2015 for which she was given a course of Albendazole, Prednisolone and antiepileptic medications. During the following 2 year period, patient developed recurrent seizures and abnormal behavior for which patient was investigated and new neurocysticercosis lesions were found in MRI Brain despite previous complete antiparasitic treatment and adherence to diet and antiepileptic medication. Patient had received courses of Albendazole (4 times) with combination of Ivermectin (1 time), and with course of Praziquantel (1 time). So we are reporting this rare case of neurocysticercosis resistant to conventional, routinely used antihelminthic medications.
Keywords: Neurocycticercosis, Albendazol resistance, Praziquantel, Seizure, Antihelminthic
Cysticercosis caused by larval stage of the tapeworm Taenia solium, is a major public health problem, both in resourcepoor as well as western developed countries. It is the single most common cause of epilepsy in the resource-poor endemic regions of the world including most of South and Central America, India, South-east Asia, China and sub-Saharan Africa1,2. Humans are only definitive host of Taenia solium harboring the adult tapeworm in the intestine. Both humans and pigs act as intermediate hosts and harbour Taenia solium
larvae in different internal organs including the brain. Humans and pigs acquire cysticercosis through ingestion of eggs excreted in faeces of human carriers. Taenia solium infection is also being increasingly diagnosed in western, affluent countries because of human migration from, and travel to endemic areas. It is common in communities where pigs roam freely and people consume undercooked pork3. Neurocysticercosis is central nervous system (CNS) infection with Taenia solium. It is perhaps the commonest parasitic infestation of the CNS, and has received attention in the last two decades because of the availability of MRI and CT scanning in the countries where cysticercosis is endemic.
25 years old, 54 kg, female presented with history of focal seizures in January 2015. Patient had no any other history like fever, head trauma, chronic cough, Tuberculosis. Patient had history of recent first trimester abortion. Past and Family history were not significant. Patient was mixed by diet eating non-vegetarian diet most of the days in month and had poor hygiene. On examination, patient had unremarkable general and systemic examinations except Fundus showing bilateral papilloedema. Patient’s routine investigations were also within normal limit including blood sugar and serum electrolytes. Stool examination for ova and cyst was negative. T.solium antibody test was positive. Chest X-ray was normal. Mountox test was negative. HIV and VDRL were non
reactive. MRI Brain suggestive of disseminated numerous subcentimeter sizes cystic lesions in bilateral cerebral hemisphere, cerebellar hemisphere, basal ganglia and midbrain with eccentric scolex. Most lesions showing perilesional edema and few lesions showing ring enhancement on post contrast study. Few lesions were calcified. These findings were suggestive of various stages of neurocysticercosis. So we gave to patient a course of Tab Albendazole 400mg BID for 4 weeks with Tab Prednisolone 40mg daily with tapering doses and antiepileptic medication (first course).
This patient again developed focal seizures in July 2015. Patient’s adherence about diet and medication was checked to which she was properly adhered. MRI Brain was again done which was suggestive of various stages of neurocysticercosis. So we again gave Tab Albendazole 400mg BID for 4 weeks under cover of steroid to the patient (second course). In September 2016, this patient again developed headache and altered behavior. Patient’s MRI Brain showed various stages of neurocysticercosis. So patient was given a course of Tab Albendazole 400mg BID for 4 weeks with Tab Ivermectin 12mg daily for 15 days (third course).
Again in February 2017, patient presented with parosmia, abnormal behavior and focal seizure. Repeated MRI Brain showed various stages of neurocysticercosis with colloid vesicular stage with perilesional vasogenic edema in right frontotemporal and parietal region. Extraocular muscles were spared. We planned biopsy of brain lesion to rule out Tubercular granuloma but patient did not give consent for the same. As patient had active neurocysticercosis, patient was given a course of Tab. Praziquantel 900mg. TID (50mg/
kg body weight / day) with Tab Albendazole 400mg BID for 4 weeks (fourth course). Anti-epileptic drug was continued. On may 2017, patient came back for follow up, she was asymptomatic, MRI brain revealed clearance of almost all neurocysticercosis lesions and patient desire to stop all the drugs for future. Now she is living seizer free life without any medications.
Despite receiving proper antihelminthic treatment, patient had persistent symptoms and lesions of neurocysticercosis in brain. This is a rare case of albendazole resistant neurocysticercosis This patient has fulfilled the diagnostic criteria for human cysticercosis. Presence of 1 absolute criterion out of 3 is required for a definitive diagnosis as proposed by Del Brutto et al4 i.e. Cystic lesions containing the characteristic scolex
on CT or MRI Brain. Other 2 absolute criteria are demonstration of cysticerci by histologic or microscopic examination of biopsy material, and visualization of the parasite in the eye by fundoscopic examination. These other 2 criteria were not met in our patient.
Neurocysticercosis is one of the common helminthic condition of the brain presented with seizure. And Albendazole is used as a drug for neurocysticercosis world wide particularly in developing countries. Although resistance of cysticercosis to Albendazole in humans has been reported in literature very rarely it may occur though5. So this case is most unusual.
Authors are thankful to Dr. Savitri Verma- Asst. Professor Obstetrics and Gynecology department, RNT medical college for referring and brought into notice the case to medicine department for management of seizures. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
1. Garcia H H and Del Brutto O H. A Imaging findings in neurocysticercosis; Acta Tropica 2003;87:71–78.
2. Prasad A, Gupta R K. Nath K, Pradhan S, Tripathi M, Pandey C Mand Prasad K N a .What riggers seizures in neurocysticercosis?– A MRI based Study in Pig Farming Community from a District of North India; Parasitol Int 2008;55; 166–171. 3.
3. Prasad K N, Prasad A, Gupta R K, Pandey C M and Uttam S.Prevalence and associated risk factors of T. solium taeniasis in a rural pig farming community of North India; Trans R Soc Trop Med Hyg 2007;101:1241–1247.
4. Del Brutto O. H, V. Rajshekhar, A. C. White Jr, V. C. Tsang, T. E. Nash, O. M. Takayanagui. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001, 57:177-183.
5. Graciela Cárdenas1, Roger Carrillo-Mezo et al. Subarachnoidal Neurocysticercosis non-responsive to cysticidal drugs: a case series. BMC Neurology 2010, 10:16.